Companion Document
835
835 Health Care Claim Payment/Advice Basic Instructions This section provides information to help you prepare for the ANSI ASC X12 Health Care Claim Payment/Advice (835) transaction. The remaining sections of this appendix include tables that provide information about 835 segments and data elements that are used to efficiently process transactions through Anthem Blue Cross systems. Use this companion document in conjunction with both the Transaction Set Implementation Guide “Health Care Claim Payment/Advice, 835, ASCX12N 835 (004010X091),” May 2000, and the subsequent Addenda (004010X091A1), October 2002, published by the Washington Publishing Co. EDI Transmission Structure Communications Transport Protocol Interchange Control Header (ISA)
Functional Group Header (GS)
Transaction Set Transaction Set
Functional Group 1 Wrap
Transaction Set Header (ST)
Transaction Set Header (ST)
Detail Segment 1 Transaction Set Trailer (SE)
EDI Transaction Structure Interchange Control Header (ISA)
Detail Segment 2
Functional Group Header (GS)
Transaction Set Trailer (SE)
Transaction Set Header (ST)
Transaction Set Trailer (SE)
Envelope
Transaction Set Header (ST)
Detail Segment 1
Envelope
Transaction Set
Transaction Set Header (ST)
Transaction Set
Functional Group Header (GS)
Envelope
Functional Group Trailer (GE)
Functional Group 2 Wrap
Interchange Control Wrap
Communications Session
Functional Group Header (GS)
Header Detail Summary Transaction Set Trailer (SE)
Functional Group Trailer (GE) Interchange Control Trailer (IEA)
Detail Segment 2
Transaction Set Trailer (SE) Functional Group Trailer (GE)
Interchange Control Trailer (IEA)
Communications Transport Protocol
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
Registration Process - Remittances and Electronic Funds Transfer (EFT) The 835 Electronic Remittance Advice (ERA) provides information for the payee regarding claims in their final status, including information about the payee, the payer, the amount, and any payment identifying information. All trading partners are eligible to receive the ERA and payment by EFT but require prior registration with EDI Solutions, (800) 227-3983, for the necessary set up and instructions. As part of the process, the ERA/EFT Enrollment Form must be completed. It is available from the EDI website (http://www.anthem.com/edi, Register). Changes to the NPI, provider or tax identification numbers may affect the distribution of the 835 Payment/Advice, therefore, providers should notify Anthem Provider Services and EDI Solutions when these types of changes do occur.
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Electronic Funds Transfer (EFT) In order to sign up for EFT, complete and submit the ERA/EFT Enrollment Form. The same form is used to submit any changes to your EFT setup. Questions about the direct deposit system can be made directly to (800) 227-3983.
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Basic Format of the 835 File - Payment by NPI, Payee ID, Multiple Providers Claim payments are made based on the NPI (or Payee ID) and Tax ID Number. Depending on the reimbursement arrangement, multiple providers may be paid under their group NPI (or group Payee ID) and Tax ID. Therefore, when a provider group requests an 835, by default all provider payments linked to the group NPI (or group Payee ID) will appear on the 835. Note that all registered NPIs will be returned on the 835. The format of the 835 file will show multiple checks and/or payment information tied to the provider group or individual provider on a given day in one or multiple ERA files. Checks and/or payment information can be bundled and uniquely identified within the same 835 file. Multiple checks and/or payment information within one 835 file may cause difficulty and require system changes for providers who directly download 835 files.
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Delimiters Anthem will use the delimiters as defined in the table below for all outbound transactions.
Anthem Blue Cross
Delimiter
Character Name
Character
Data Element Separator Sub-Element Separator Segment Terminator
Asterisk Bar Tilde
* | ~
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835 Health Care Claim Payment/Advice Companion Document
Claim Adjustment Group Code The Claim Adjustment and Service Adjustment Segments (CAS) provide the reasons, amounts, and quantities of any adjustments that the payer made either to the original submitted charge or to the units related to the claim or service(s). Specifically, the Claim Adjustment Group Code (CAS01) categorizes the adjustment reason codes contained in a particular CAS and are evaluated according to the following order: 1. Patient Responsibility (PR) — indicates the amount adjusted in CAS segment is the patient’s responsibility. 2. Contractual Obligations (CO) — indicates the amount adjusted in CAS segment is not the patient’s responsibility due to a contractual obligation between the provider and the payer. 3. Payer Initiated Reductions (PI) — indicates the amount adjusted in CAS segment is not the patient’s responsibility, without a supporting contract between the provider and the payer. 4. Correction and Reversals (CR) — indicates the claim is the reversal of a previously reported claim or claim payment. 5. Other Adjustments (OA) — indicates the amount adjusted does not fall in any of the above categories.
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Claim Adjustment Reason Codes and Remittance Advice Remark Codes A claim adjustment reason code (CAS segment) is used to communicate that an adjustment was made at the claim/service line, and provides the reason for why the payment differs from what was billed. The adjustment reason code list is available on the internet (http://www.wpc-edi.com/ codes, select Claim Adjustment Reason Codes) and reviewed by the Claim Adjustment Status Code maintenance committee three times a year. A claim remittance advice remark code (LQ segment) provides supplemental explanation for an adjustment already described by an adjustment reason code. Previously, the remittance remark code list was created and supported for Medicare only, but now it is appropriate for use by all payers. The remark code list is available on the internet (http://www.wpc-edi.com/codes, select Remittance Advice Remark Codes) and reviewed by the Remittance Advice Code Maintenance Committee whose members represent various components from CMS. It is important to continue referring to the code lists maintained by the committees. Updated code lists are published tri-annually at the end of March, July, and November. The use of HIPAA standards has imposed a limitation on what detailed explanation is reported on the 835 Payment/Advice. It has been determined that proprietary disposition codes may not map onefor-one to a standard HIPAA claim adjustment reason and/or remittance advice remark code.
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
Provider Level Adjustment (PLB) The provider level adjustment, PLB segment, is reported after all the claim payments in the Summary of the 835 transaction. This segment is used for takeback notification and actual takebacks, and the detailed information of the adjusted claim is reported at the claim level, CLP segment. Example:
PLB03 Data Element
PLB*941400001*20081231*WO:9730000048070714400575*1205.31 Provider Tax ID (EIN)
End of Fiscal Year
Adjusted Amount Adj Reas Code
DCN
Claim Date
Patient Account #
The third data element, PLB03, in the PLB segment is a composite segment with four distinct values, the Adjustment Reason Code, followed by a value composed of the Document Control Number (DCN), Claim Date, and Patient Account Number.
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PLB03-1:
The Adjustment Reason Code (FB, IR, PI, L6, WO) identifies the type of adjustment.
PLB03-2:
DCN is the claim number Anthem Blue Cross uses to identify the payment made to the provider. Date of when the claim was originally processed (070714). Patient Account Number assigned by provider to track claim processing (400575).
PLB04:
The PLB will decrease when the adjustment amount is positive. The PLB will increase when the adjustment amount is negative.
Balancing To ensure HIPAA compliance, editing is performed on the 835 transaction as it is routed through the Enterprise EDI Gateway/Clearinghouse. Successful outbound routing to the 835 trading partner depends on the balancing of the file where the total payment must agree with the remittance information detailing that payment. The amounts reported in the file must balance at three different levels; the service line, the claim, and the transaction. When service payment information is provided, the submitted service charge (SVC02) minus the sum of all monetary adjustments (CAS segments) must equal the amount paid for the service line (SVC03). Similarly within the claim payment loop, the submitted charge for the claim (CLP03) minus the sum of all monetary adjustments (CAS segments) must equal the claim paid amount (CLP04). The total claim charge (CLP03) must balance the sum of the related service charges (SVC02), if applicable. *Monetary amounts in the AMT segments convey information only; they do not affect the financial balancing of the transaction. Further balancing within the transaction ensures that the sum of all claim payments (CLP04) minus the sum of all provider level adjustments (PLB segments) equals the total payment amount (BPR02).
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice – Header The 835 Payment/Advice Header contains general payment information, such as Amount, Payee, Payer, Trace Number and Payment method. The following table explains the header segments and data elements that require specific information for Anthem Blue Cross processing.
835 Health Care Claim Payment/Advice—Header IG
P.44
Segment
BPR Financial Information
Reference Designator(s) BPR01 Transaction Handling Code BPR02 Total Actual Provider Payment Amount BPR03 Credit/Debit Flag Code BPR04 Payment Method Code
Value
I H
Definitions and Notes Specific to Anthem Blue Cross I - Remittance Information Only H - Notification Only
Amount must be equal to or greater than (Total Actual Provider Payment zero. Amount) C - Credit to the provider's account C ACH CHK NON CCP
ACH - Automated Clearing House CHK - Check NON - Non-Payment Data CCP - Cash Concentration/Disbursement plus Addenda 01 - ABA Transit Routing Number *ABA is not to be confused with Anthem Benefit Administrators.
BPR05 Payment Format Code 01 BPR06 Depository Financial Institution (DFI) ID Number Qualifier Represents Anthem's Bank number. (Sender DFI BPR07 (DFI) ID Number Identifier) Represents Anthem's Bank Account (Sender Bank BPR09 Account Number Account Number) number. 01 - ABA Transit Routing Number 01 BPR12 *ABA is not to be confused with Anthem (DFI) ID Number Benefit Administrators. Qualifier Represents Receiver/Provider's Bank (Receiver DFI BPR13 number. (DFI) ID Number Identifier) Represents Receiver/Provider's Bank (Receiver Bank BPR15 Account Number Account Number) Account number. Date when check was created. (Check Issue BPR16 Check Issue or EFT Date) Effective Date TRN segment provides Trace No. to reassociate dollars (payment) to remittance data (835). P.52 TRN 1 - Current Transaction Trace Number 1 TRN01 Reassociation Trace Code Type Trace Number TRN02 ▪ Check No. - if provider receives paper. (Check or EFT ▪ Advice No. - if provider receives EFT. Reference Identification Trace Number) ▪ NO PAYMENT - if BPR02 = $0.00 NO PAYMENT (Payer Identifier) Represents Anthem's Tax ID No. TRN03 preceded by '1'. Originating Company ID
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice—Header IG
Segment
Reference Designator(s)
Value
Definitions and Notes Specific to Anthem Blue Cross
P.57
REF Applies to Institutional FEP Payments only. EV - Receiver ID Number Receiver REF02 EV Identification Reference ID Qualifier Represents payments for FEP claims. FEP REF02 Reference Identification P.60 DTM 405 - Production DTM01 405 Production Date Time Qualifier Date Scheduled remittance run date. DTM02 (CCYYMMDD) Production Date P.69 PER Applies to Institutional FEP Payments only. Contact Name of Payer. Payer PER02 (Payer Contact Contact Name Name) Information Contact Phone Number. (Payer PER04 Communication Communications Number Number) Loop ID 1000B—Payee Identification P.72 N1 Represents the Pay-to Provider. N102 (Payee Name) Payee Name Identification N103 XX - National Provider Identifier XX FI - Federal Taxpayer's Identification number ID Code Qualifier FI • NPI ('XX') for Non-Exempt providers N104 (Payee • Tax ID ('FI') for Exempt providers Identification Code Identification Code) P.77 REF TJ - Federal Taxpayer's Identification number TJ REF01 PQ - Payee Identification Payee Reference ID PQ Additional Qualifier Identification REF02 • Tax ID ('TJ') for Non-Exempt providers (Additional Reference Payee Identifier) • Payee ID ('PQ') for Exempt providers Identification
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice – Detail The 835 Payment/Advice Detail level contains the explanations of benefits/charges paid, reduced or denied, related to the adjudicated claims and services. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements, in these Loops that are used for Anthem Blue Cross processing.
835 Health Care Claim Payment/Advice—Detail IG
Segment
Reference Value Designator(s) Loop ID 2100—Claim Payment Information P.89 CLP (Patient Control CLP01 Claim Claim Submitter's Number) Payment Identifier Information CLP02 1 4 Claim Status Code 2 22 3 12 15 CLP06 Claim Filing Indicator 13 HM Code 14 MC
P.102 NM1 Patient Name P.105 NM1 Insured Name P.108 NM1 Corrected Patient / Insured Name P.111 NM1 Service Provider Name
P.130 DTM Claim Date P.132 PER Payer Contact Information
Anthem Blue Cross
CLP07 Reference NM108 ID Code Qualifier NM109 Identification Code NM108 ID Code Qualifier NM109 Identification Code NM101 Entity Identifier Code
NM103, (NM104) Name Last (First) or Org Name NM108 ID Code Qualifier NM109 Identification Code
Definitions and Notes Specific to Anthem Blue Cross
Value populated from inbound electronic 837 CLM01 or from paper claim: Block 26 (HCFA, CMS1500), Block 3 (UB92, UB04). 1 - Claim processed as Primary; 2 Secondary; 3 - Tertiary; 4 - Denied; 22 Reversal 12 - Preferred Provider Org. (PPO); 13 - Point of Service (POS); 14 - Exclusive Provider Org. (EPO); 15 - Indemnity Insurance (may include Traditional Plans); HM - HMO; MC - Medicaid Represents the internal claim number (Payer Claim Control Number) assigned by Anthem. MI - Member Identification Number MI (Patient Identifier) MI
Membership Number assigned by Anthem.
(Subscriber Identifier) 74
Membership Number assigned by Anthem.
(Rendering Prov Last (First) or Org Name) XX FI (Rendering Prov Identifier)
Represents the name populated on the 837 at the line level (Loop 2400).
MI - Member Identification Number
74 - Corrected Insured
XX - National Provider Identifier FI - Federal Taxpayer's Identification number • NPI ('XX') for Non-Exempt providers • Tax ID ('FI') for Exempt providers
050 - Received 050 DTM01 Date/Time Qualifier Represents the date the claim was received DTM02 (Claim Date) by Anthem. Claim Date Applies to Anthem Blue Cross Payments only. Claim Contact Name of Payer. PER02 (Claim Contact Name Name) Contact Phone Number. (Claim Contact PER04 Communication Communications Number Number)
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice—Detail IG
Segment
Reference Value Definitions and Notes Designator(s) Specific to Anthem Blue Cross Loop ID 2110—Service Payment Information P.139 SVC SVC01-1 AD - American Dental Association Codes Product Service ID Service HC - Health Care Financing Administration Common Procedural Qualifier Payment Coding System (HCPCS) Codes Information ID - ICD-9-CM - Procedure ND - National Drug Code (NDC) NU - National Uniform Billing Committee (NUBC) UB92 Code ZZ - Mutually Defined Applicable when 1) adjudicated proc code in (Product or SVC06-1 ― 06-7 SVC01 differs from submitted proc code on Product/Service ID Service ID original claim, 2) to reference originally Qualifier Qualifier) submitted proc on rebundled claim, and 3) to reference Anthem medical policy changes. P.146 DTM Service Date P.148 CAS Service Adjustment
DTM02 Date CAS01 Claim Adjustment Group Code
(Service Date) Format CCYYMMDD CO CR OA PR
CO - Contractual Obligation (Prov Write-off) CR - Corrections & Reversals (Adjustments) OA - Other Adj (Bundled Lines, Non-Covered Charges) PR - Patient Resp (Copayment, Deductible) Represents adjustments at service line level.
(Adjustment CAS02,5,8,11,14,17 Claim Adjustment Reason Code) Reason Code CAS03,6,9,12,15,18 (Adjustment Monetary Amount Amount) CAS04,7,10,13,16,19 (Adjustment Quantity Quantity) P.154 REF 6R - Provider Control Number REF01 6R Service Reference ID Qualifier Identification REF02 Represents Line Item Control Number (Provider submitted on 837 Claim. Reference Identification Identifier) P.158 AMT AMT segment conveys information only. It does not affect financial balancing. B6 - Allowed - Actual Service AMT01 B6 Supplemental Amount Qualifier Code Amount Represents the Anthem Allowed Amount for the AMT02 (Service Monetary Amount Supplemental service. Amt) HE - Claim Payment Remark Codes P.162 LQ HE LQ01 Health Care Code List Qualifier Remark Code Codes LQ02 (Remark Code) Maximum of 5 remark codes per line. Industry Code
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice – Summary The 835 Payment/Advice Summary level contains the Provider level adjustments, which provides information related to adjustments to the payment amount not specific to the claims in the 835 Payment/Advice Detail level. The following table identifies the situational segments and data elements, and specific values of the required segments and data elements, in these Loops that are used for Anthem Blue Cross processing.
835 Health Care Claim Payment/Advice—Summary IG
Reference Value Definitions and Notes Designator(s) Specific to Anthem Blue Cross The PLB Segment is used to allow adjustments that are NOT specific to a particular claim or service. P.164 PLB Represents the Payee ID Number assigned by PLB01 (Provider Anthem. Reference Identification Identifier) Provider Adjustment PLB03-1 FB - Forwarding Balance FB IR - Internal Revenue Service Withholding Adjustment Reason IR L6 - Interest Owed Code L6 PI - Periodic Interim Payment PI WO - Overpayment Recovery WO
Anthem Blue Cross
Segment
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835 Health Care Claim Payment/Advice Companion Document
Enveloping This section explains EDI enveloping of the 835 Payment/Advice transaction that will help you when receiving responses from Anthem (Anthem Blue Cross). EDI envelopes control and track communications between you and Anthem (Anthem Blue Cross). One envelope may contain many transaction sets grouped into functional groups. The envelope includes the following components:
Interchange Control Header (ISA) Functional Group Header (GS) Functional Group Trailer (GE) Interchange Control Trailer (IEA)
835 EDI Transaction Structure Interchange Control Header (ISA) Functional Group Header (GS)
Envelope
Envelope
Envelope
Transaction Set Header (ST)
Header Detail Summary Transaction Set Trailer (SE)
Functional Group Trailer (GE) Interchange Control Trailer (IEA)
Anthem Blue Cross
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835 Health Care Claim Payment/Advice Companion Document
835 Envelope Control Segments 1
835 Health Care Claim Payment/Advice Interchange Control Header (ISA) The ISA segment is the beginning, outermost envelope of the interchange control structure. Containing authorization and security information, it clearly identifies the Sender, Receiver, Date, Time, and Interchange Control Number. Use the following table, specific to Anthem, to supplement the 835 Implementation Guide. This information does not modify the 835 Implementation Guide.
835 Health Care Claim Payment / Advice Interchange Control Header (ISA) Segment
Reference Designator(s)
ISA Interchange Control Header
ISA01 Auth Information ISA02 Authorization Information ISA03 Security Info Qualifier ISA04 Security Information ISA05 Interchange ID Qualifier ISA06 Interchange Sender ID ISA07 Interchange ID Qualifier ISA08 Interchange Receiver ID ISA09 Interchange Date ISA10 Interchange Time ISA11 Interchange Control St d d Identifier Standards Id tifi ISA12 Interchange Control Version Number ISA13 Interchange Control Number
ISA14 Acknowledgment Requested ISA15 Usage Indicator ISA16 Component Element Separator
Anthem Blue Cross
Value
00
Definitions and Notes Specific to Anthem Blue Cross 00 - No Authorization Information Present
(10 Spaces) 00
00 - No Security Information Present
(10 Spaces) ZZ
ZZ - Mutually Defined
ANTHEM BCCA SRFACETS ZZ
ANTHEM - Anthem (for Institutional FEP only) BCCA - Anthem Blue Cross SRFACETS - SRFACETS MA PFFS ZZ - Mutually Defined
(Receiver ID) (YYMMDD)
EDI Assigned Receiver ID representing the 835 receiver. Valid date in YYMMDD format.
(HHMM)
Valid time in HHMM format.
U
U - U.S. EDI Community of ASC X12, TDCC, and UCS
00401
00401 - Draft Standards for Trial Used Approved for Publication by ASC X12 Procedures Review Board through October 1997 ▪ Format - 9 position numeric. ▪ Unique value greater than zero, not used in previous HIPAA transaction within 30 calendar day period. ▪ Right-justified, Right-justified filled with leading zeroes zeroes. ▪ Identical to value in IEA02. 0 - No Acknowledgment Requested
(Assigned by Sender)
0 P, T |
Submitter ID must be approved to receive production data. P - Production Data; T - Test Data Vertical e t ca Bar a (|) will be se sentt as tthe e Co Component po e t Element Separator.
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835 Health Care Claim Payment/Advice Companion Document
835 Health Care Claim Payment/Advice Functional Group Header (GS) The GS segment identifies the collection of transaction sets that are included within the functional group. More specifically, the GS segment identifies the functional control group, sender, receiver, date, time, group control number and version/release/industry code for the transaction sets. Use the following table, specific to Anthem Blue Cross, to supplement the 835 Implementation Guide. This information does not modify the 835 Implementation Guide.
835 Health Care Claim Payment / Advice Functional Group Header (GS) Segment
GS Functional Group Header
Reference Designator(s) GS01 Functional Identifier Code GS02 Application Sender's Code GS03 Application Receiver's Code GS04 Date GS05 Time GS06 Group Control Number
Value
HP
HP - Health Care Claim Payment / Advice (835) Routing from:
ANTHEMFCS BCCA SRFACETS (Receiver ID)
ANTHEMFCS - FEP (Institutional only) BCCA - Anthem Blue Cross SRFACETS - SRFACETS MA PFFS EDI Assigned Receiver ID representing the 835 receiver receiver.
(CCYYMMDD)
Valid date in CCYYMMDD format.
(HHMM)
Valid time in HHMM format.
((Assigned g y by Sender)
▪ Format - 1-9 p position numeric. ▪ Unique value greater than zero, not used in previous HIPAA transaction within 30 calendar day period. ▪ Right-justified, filled with leading zeroes. ▪ Identifical to value in GE02. X - Accredited Standards Committee X12
GS07 X Responsible Agency Code GS08 004010X091A1 Version / Release / Industry Identifier Code
Anthem Blue Cross
Definitions and Notes Specific to Anthem Blue Cross
Operationally used to identify the 835 Health Care Claim Payment / Advice transaction.
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835 Health Care Claim Payment/Advice Companion Document
All balancing measures must be met in order for an 835 file to be delivered to the Gateway.
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835 Health Care Claim Payment/Advice Functional Group Trailer (GE) The GE segment indicates the end of the functional group and provides control information. Use the following table, specific to Anthem, to supplement the 835 Implementation Guide. This information does not modify the 835 Implementation Guide.
835 Health Care Claim Payment / Advice Functional Group Trailer (GE) Segment
Reference Designator(s)
GE01 GE Number of Functional Group Trailer Transaction Sets Included GE02 Group Control Number
4
Value
(Total Number of Transaction Sets in Functional Group or Transmission) (Control Number)
Definitions and Notes Specific to Anthem Blue Cross ▪ Format - 1-6 positions, numeric. ▪ Left-justified with no trailing zeroes or spaces. ▪ Format - 1-9 positions, numeric. ▪ Left-justified with no trailing zeroes or spaces. ▪ Identical to GS06.
835 Health Care Claim Payment/Advice Interchange Control Trailer (IEA) The IEA segment is the ending, outermost level of the interchange control structure. It indicates and verifies the number of functional groups included within the interchange and the interchange control number (the same number indicated in the ISA segment). Use the following table, specific to Anthem, to supplement the 835 Implementation Guide. This information does not modify the 835 Implementation Guide.
835 Health Care Claim Payment / Advice Interchange Control Trailer (IEA) Segment
IEA Interchange Control Trailer
Anthem Blue Cross
Reference Designator(s) IEA01 Number of Included Functional Groups IEA02 Interchange Control Number
Value
(Number of Functional Groups GS/GE Pairs in Interchange) (Control Number)
Definitions and Notes Specific to Anthem Blue Cross ▪ Format - 1-5 positions, numeric. ▪ Left-justified with no trailing zeroes. ▪ Format - Fixed length 9 positions, numeric. ▪ Unique value greater than zero. ▪ Identical to ISA13.
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